DOI: 10.7860/JCDR/2015/11206.

5499
Case Report

Combined Gastric and Duodenal

Surgery Section
Perforation Through Blunt
Abdominal Trauma
Bimaljot Singh1, Adarshpal Kaur2, Rachan Lal Singla3, Ashwani Kumar4, Manish Yadav5

ABSTRACT
Blunt abdominal traumas are uncommonly encountered despite their high prevalence, and injuries to the organ like duodenum are
relatively uncommon (occurring in only 3%-5% of abdominal injuries) because of its retroperitoneal location. Duodenal injury combined
with gastric perforation from a single abdominal trauma impact is rarely heard. The aim of this case report is to present a rare case of
blunt abdominal trauma with combined gastric and duodenal injuries.

Keywords: Blunt abdominal trauma, Feeding jejunostomy, Gastrojejunostomy, Tube duodenostomy

Case report which he was managed in ward. The patient did well and feeding
An 18-year-old man was brought to emergency surgery ward with a Jejunostomy was started slowly over a period of time along with
history of trauma two days back from a handcart taking bricks in a reinstallation of bile coming out of Malecot catheter drain mixed with
brickkiln factory. The patient was diagnosed as having a perforation, milk through feeding jejunostomy. Contrast study was performed
detected at some local hospital, from air under diaphragm. The by injecting a radiopaque dye through Malecot catheter on 14th
patient could not be operated there because he was in shock postoperative day, which showed no leakage from anywhere [Table/
for two days, for which he was resuscitated and an abdominal Fig-4]. Contrast-enhanced CT was also carried out for conformation,
drain was put in right flank under local anesthesia. The patient
presented to us in a dehydrated condition, conscious, with signs of
peritonitis. Exploratory laparotomy was planned and the patient was
immediately shifted to Operation Theater. A midline laparotomy was
carried out. On opening the peritoneal cavity, Ryles tube was seen
coming out and a big gastric perforation was identified [Table/Fig-1].
On exploration, two perforations were suspected, which were made
clear after kocherization of duodenum was performed. There was
a big perforation of anterior wall of stomach extending from lesser
curvature to greater curvature and another in the second part of
duodenumtotal transaction, just proximal to ampulla of Vater
opening [Table/Fig-2].
Primary repair of duodenal transaction over Malecot catheter (tube
duodenostomy) was carried out. Laceration over anterior wall of
stomach was repaired with gastrojejunostomy. Feeding jejunostomy
was also performed [Table/Fig-3]. Two drains were kept, one in the
Morrisons pouch and another in the pelvic cavity. Postoperatively,
the patient was kept in the intensive care unit for four days after
[Table/Fig-2]: Showing sites of perforations

[Table/Fig-1]: Ryles tube seen out of perforated stomach [Table/Fig-3]: Showing repairs done

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www.jcdr.net Bimaljot Singh et al., Combined Gastric and Duodenal Perforation Through Blunt Abdominal Trauma
[Table/Fig-4]: Showing no leakage after injecting Radioopaque contrast through
Malecot s catheter
[Table/Fig-5]: Showing Malecots catheter, Morrisons drain, and feeding
jejunostomy in situ
which again showed no leakage. Clear water was started orally and
Malecot catheter was clamped. Then other liquids and semi solids
were started, which patient tolerated well without any abdominal
distension. During this period drain in the Morrisons pouch showed
minimal serous discharge, which was non-bilious, confirming no
leakage from anywhere. Malecots catheter was removed on the
28th postoperative day, which did not increase any further discharge
from Morrisons drain [Table/Fig-5]. Morrisons drain and feeding
jejunostomy were removed on the 30th postoperative day.
Discussion
Isolated duodenal rupture following blunt abdominal trauma is rare.
It is seen in approximately 2%20% of patients with blunt abdominal
injury and often results in after blows to the upper abdomen, or
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abdominal compression due to the common mechanism of high-
riding seat belts [15].The management of duodenal injuries is
still controversial, and there is a lack of consensus on the optimal
treatment. In approximately 70%-85% cases, all duodenal injuries
can be treated safely by primary repair. Duodenal injuries can be
serious when the total amount of fluid passing through the duodenum
exceeds 6 L per day [5]. Serious fluid and electrolyte imbalance can
also be caused by a fistula present in this region. Complications
may become life-threatening if a large amount of activated enzymes
gets liberated into retroperitoneal space and peritoneal cavity [5].
If the disruption is less than 50% of the circumference, with regular
injury border, adequate blood supply and without serious peritoneum
pollution, the duodenum injury could be closed transversely and
jejunostomy can be opted for decompression of duodenum. In
75%-85% of cases, duodenum injury could be closed primarily, and
chances of duodenal fistula are less than 10% [6].
However, if the disruption is more than 50% of the circumference or
there is a possibility that primary closure of the defect may narrow
the lumen of the bowel or result in undue tension and subsequent
breakdown of the suture lines, we may advise segmental resection
and primary end-to-end duodenoduodenostomy, especially in case
of injury of the first, second, or third part of the duodenum [7].
Suture of two ends without causing undue tension on the suture
line is impossible if a large part of duodenum is lost. Surgeries of
duodenal diverticulization, which include closure of the duodenal
injury, gastric antrectomy with end-to-side gastrojejunostomy,
tube duodenostomy, and generous drainage in the region of the
duodenal repair, should be performed if a large tissue of the first
part of duodenum is lost [8]. As duodenal diverticulization is a time-
consuming process, it is not recommended in hemodynamically
unstable patients or when there are several accompanied injuries.
Closure of distal duodenum and Roux-en-Y duodenojejunostomy is
an appropriate choice if the injury is distal to the ampulla of Vater. If
the second part of the duodenum is injured, a direct anastomosis of
Roux-en-Y over the injury in an end-to-side manner is appropriate
because of the limited mobilization of this part. In case primary
anastomosis is not possible, this procedure can be also applied to
other parts [9].
There are also other concomitant surgically important intra-
abdominal injuries in 40% of patients with duodenal injury and these
are hepatic (38%) or pancreatic (28%) injuries [10]. But combined
gastric and duodenal perforation is rare and its documentation in
literature is not available. A preoperative diagnosis of the perforations
present is difficult to make, and surgeon is always in dilemma of
choosing between several preoperative investigations and surgical
procedures.
Theoretically, duodenal perforation is associated with a leak of
amylase and other digestive enzymes and determination of serum
amylase concentration may be helpful in diagnosis [5,11]. However,
the tests lack sensitivity [12,13]. Although the specifics of the grading
system are useful for research purposes, they are less important
than several simple aspects of the duodenal injury [5]:
The anatomical relation to the ampulla of Vater.
The characteristics of injury (simple laceration versus destruction
of duodenal wall).
The involved circumference of duodenum.
The injury associated to stomach, biliary tract, pancreas, and
major vessels.
As in our case, duodenal injury was associated with stomach injury
due to direct trauma to abdomen. The number of such injuries has
increased because of frequent automobile accidents and violent
events [14].
Abdominal plain films, ultrasonic test, and CT scan can also help in
diagnosis. Free air under diaphragm, retroperitoneal air, obliteration
of Psoas muscle shadow, and scoliosis of lumbar vertebrae can give
31
 Bimaljot Singh et al., Combined Gastric and Duodenal Perforation Through Blunt Abdominal Trauma www.jcdr.net

clue to injury [15]. In case of absence of positive signs, air or water-
soluble radio-opaque contrast can be injected through nasogastric
tube and its leakage can be easily detected. Barium is not used
as it is difficult to clear up during surgery and may lead to infection
postoperatively. Although routine preoperative laboratory tests are
not helpful in diagnosis but some authors find that serum amylase
is an important marker. Serum amylase level is found to be raised in
50% cases of upper gastrointestinal or duodenal injury [16].
If there is a high degree of suspicion, exploratory laparotomy is the
ultimate diagnostic test. The explorative procedures need to be
careful, comprehensive, accurate, and quick. Blocksom and co-
workers [17] reported that if systolic blood pressure is lower than
90 mm Hg before surgery, the mortality can reach 46%, and if a
patient needs transfusion more than 1000 ml, his/her hospital stay
will be apparently longer. So, we should pay attention to controlling
bleeding, correcting shock, and preventing infection during early
hours of treatment. At the same time, surgery should be planned,
and depending on the injuries found, meticulous repair should be
carried out by experts. In our case, gastric perforation was dealt
with primary repair by gastrojejunostomy, with duodenal repair
over Malecot catheter with feeding jejunostomy for nutritional
supplementation as nutritional supplementation through a
jejunostomy tube is beneficial [17].
Conclusion
Combined gastric and duodenal perforation is rare. Delay in diagnosis
and planning surgery can prove fatal for the patient. Early detection,
early diagnosis, and early treatment of injuries has shown good
prognosis. The surgical repair (that is exploratory laparotomy) is a
safe and effective therapy for suspected gastrointestinal perforation.
Meticulous repair by experienced surgeon, either in case of isolated
gastric or duodenal or in case of combined gastric and duodenal
perforation, done timely can significantly affect the outcome.
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PARTICULARS OF CONTRIBUTORS:
1, Junior Resident, Department of Surgery, Government Medical College and Rajindra Hospital, Patiala , Punjab, India.
2. Senior Resident, Department of Surgery, Government Medical College and Rajindra Hospital, Patiala , Punjab, India.
3. Assistant Professor, Department of Surgery, Government Medical College and Rajindra Hospital, Patiala , Punjab, India.
4. Professor, Department of Surgery, Government Medical College and Rajindra Hospital, Patiala , Punjab, India.
5. Junior Resident, Department of Surgery, Government Medical College and Rajindra Hospital, Patiala , Punjab, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Bimaljot Singh, Date of Submission: Sep 11, 2014
H. No. 228/2, Chahal Street , Near Twakli Mour, Patiala, Punjab-147001, India.
Date of Peer Review: Dec 02, 2014
E-mail: drbimal.undefined@gmail.com
Date of Acceptance: Dec 20, 2014
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Jan 01, 2015

32 Journal of Clinical and Diagnostic Research. 2015 Jan, Vol-9(1): PD30-PD32